Final exam short case

  This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global

online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

A 67 old male patient came to the OPD with the chief complaint of shortness of breath and bilateral pedal edema ,pitting type since 3 days.

History of present illness:

Patient was apparently asymptomatic since 20 yrs back then he developed severe cough with sputum went to hospital and diagnosed with TB use ATT course for 9 months and relieved.

Patient developed shortness of breath of grade 2-3, grade 2 pedal edema of pitting type.

History of past illness: know case of TB. Not a know case of diabetes, hypertension, asthma, epilepsy.

Personal history:

Diet: mixed.

Appetite: decreased since 1yr.

Sleep : decreased

Bowel and bladder movements are normal.

Chronic alcoholic since 50yrs (3times a week 180-360 ml).

Chronic smoker since 50 yrs (18 beedis/day).

Drug history: not allergic to any of the known drugs 

Family history: no relevant family history.

General examination: clubbing is seen.

Vitals: 

Temperature: afebrile ,Pulse rate: 98 beats per minute, BP: 110/80 mm Hg, Respiratory rate: 26 cycles per minute, SPO2:83, GRBS :111mg/dl.

Systemic examination:

CVS: S1 and S2 heard ,bilaterally symmetrical chest wall, no thrills and murmurs heard.

Respiratory system: bilateral air entry present, wheezing present, position of trachea central.

CNS: patient is conscious and coherent.

Abdomen: distended.


Clubbing:







Investigations:









Provisional diagnosis:cor pulmonale, copd, with history of TB.
Treatment:
Inj. Lasix 40 mg IV /BD.
Fluid restriction <1.5L/ day
Salt restriction:<2g/ day.
NEB : duolin, budecort 6th hourly.
Inj. Augmentin 1.2 gm/IV/BD.
Inj. Pan 40mg IV/OD.
Inj. Thiamine 1 amp in 100ml NS /IV/TID.
BP/PR/RR/TEMP charting 4th hourly.




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